Basic Information
| Provider Information | |||||||||
| NPI: | 1760572960 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KEYS | ||||||||
| FirstName: | KENT | ||||||||
| MiddleName: | CALHOUN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KEYS | ||||||||
| OtherFirstName: | KENT | ||||||||
| OtherMiddleName: | CALHOUN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1029 CHRISTINE AVENUE | ||||||||
| Address2: | |||||||||
| City: | ANNISTON | ||||||||
| State: | AL | ||||||||
| PostalCode: | 362075709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2562370371 | ||||||||
| FaxNumber: | 2562364181 | ||||||||
| Practice Location | |||||||||
| Address1: | 1029 CHRISTINE AVE | ||||||||
| Address2: | |||||||||
| City: | ANNISTON | ||||||||
| State: | AL | ||||||||
| PostalCode: | 362075709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2562370371 | ||||||||
| FaxNumber: | 2562364181 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2006 | ||||||||
| LastUpdateDate: | 01/29/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 07/17/2007 | ||||||||
| NPIReactivationDate: | 07/26/2007 | ||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 00010962 | AL | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 000015863 | 05 | AL | MEDICAID |